Introduction: Applying vancomycin into the surgical site is well-described in spinal neurosurgery, with extensive institutional experiences and systematic reviews describing its effectiveness in reducing surgical site infections (SSIs) with an acceptable safety profile. Its use in non-spinal neurosurgical procedures is a logical extension of those findings, but the evidence base supporting it is lacking. Recent studies describing institutional experiences with its utilization have emerged with varying degrees of success.
Methods: MEDLINE, EMBASE and Google Scholar were searched through February 4th, 2018. Information on study designs, demographics, exposures, and outcomes were extracted. Estimates were combined by using random-effects models. (PROSPERO registration completed).
Results: Our search retrieved eight studies for quantitative analysis. They assess vancomycin use in craniotomies, cranioplasties, deep brain stimulator-related procedures, as well as ventriculoperitoneal shunt surgeries. The majority of studies have serious methodological shortcomings that introduce confounding. We found an overall beneficial effect on SSI incidence (OR= 0.22; 95%CI, 0.09-0.55) that was seen across all subspecialties except for cranioplasties.
Conclusions: Vancomycin use in non-spinal neurosurgery is not supported by high-quality evidence which limits the strength of the conclusions that can be drawn on the topic. Nonetheless, we show an overall favorable effect on SSIs that should be reproduced in a randomized controlled fashion prior to its application in patient care.
Patient Care: Intra-wound application of vancomycin (IWV) is a promising SSI prevention measure. Current enthusiasm should be tempered by the lack of high-quality evidence that supports its use.
We found that the majority of studies assessing the role of IWV in non-spinal neurosurgery are low quality, unblinded, retrospective studies that use historical controls. Variable doses and delivery methods have been described and thereby limiting the applicability of our meta-analysis.
We are aiming to highlight that further studies on the matter should focus on improving the quality of available evidence. Future studies should also attempt to adequately evaluate the efficacy of vancomycin across the wide range of neurosurgical scenarios with increased infection risks such as traumatic wounds, sinus transgression, cases revised for infection and revision oncology cases in immunosuppressed patients.
Learning Objectives: By the conclusion of this session, participants should be able to summarize the effect of local vancomycin application on SSIs in the context of non-spinal neurosurgical procedures while describing the quality of the supporting evidence base.